Pediatric Coding Alert

Are your pediatricians leaving off minutes on their discharge day management notes? "Some payers require time documentation when billing for discharges (99238, Hospital discharge day management; 30 minutes or less; and 99239, ... more than 30 minutes)," says Barbara Avery, revenue cycle specialist at Woodbury Clinic in Minneapolis.

Why bother? Code 99239 pays $31.45 more than 99238 using the 2007 Medicare Physician Fee Schedule. The cut-off for using 99239 is 31 minutes, says Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J.

Getting those extra dollars is fairly easy -- documentation-wise. All the pediatrician has to dictate is "spent over 30 minutes" on discharge day services, says Donelle Holle, RN, a pediatric nurse with more than 28 years of coding and billing experience for pediatric services.

Example: A pediatrician sends home a newborn who had transitory tachypnea of the newborn (TTN 770.6). The physician reviews the infant's hospital course in detail and discusses the stay with the parents. He addresses their concerns and informs them about signs of possible respiratory problems. Total discharge day management could easily take more than 30 minutes, making 99239 appropriate.

You won't, however, always use a discharge day code for a newborn that the pediatrician sends home. When a physician admits and discharges a normal newborn on the same day, do not report each service separately. Instead submit the services with a single code: 99435 (History and examination of the normal newborn infant, including the preparation of medical records [this code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date]).

Example: A mother of multiple children gives birth to a newborn at 10 a.m. The pediatrician sees the infant for the first time on rounds the next morning and determines that the transition to breast/bottle feeding is going well. There are no signs of jaundice or infant problems. The physician feels comfortable sending the patient home that evening if all goes well that day.

Because the pediatrician performs the initial history and physical (H&P) and the discharge on the same day, you should report 99435, not 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing room deliveries]) and 99238-99239. You should code an initial H&P and discharge of a normal newborn that occurs on different days with 99431 on the admit day and 99238-99239 on the discharge day.

Good news: Although you should use only one code for a same-day admit and discharge, you won't lose financially. "Code 99435 pays slightly more (about $20) than 99431 to represent the additional work and phone

calls associated with the discharge," says Richard H. Tuck, MD, FAAP, pediatrician with PrimaryCare of Southeastern Ohio in Zanesville, Ohio.

Tell your pediatricians to start thinking of history, examination and medical decision-making when they use anything other than normal newborn V30.0x on newborn in-between days. Use 99433 (Subsequent hospital care) to report days in which a physician sees a normal newborn but does not perform the initial H&P or discharge the patient.

Rule: Only link 99433 to a V30.0x normal newborn diagnosis code, such as V30.00 (Single liveborn; born in hospital; delivered without mention of cesarean delivery). If you list a "sick" diagnosis code with 99433, the insurer will deny the charge due to the CPT and ICD-9 code not matching, Holle says.

When the pediatrician is treating a problem and circles another ICD-9 code, he should select a subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...), which requires at least two of these three key components: history, examination and medical decision-making.

Subsequent hospital care pays in the middle: more than initial normal newborn care ($55), but less than discharge day management ($66 or $95), with a midlevel visit (99232, ... expanded problem-focused interval history, expanded problem-focused examination, and medical decision-making of moderate complexity) paying about $64. Be aware that you should use these codes for abnormal newborns, Tuck says.

Example: A pediatrician performs an initial H&P of a normal newborn on day 1. On day 2, the infant develops hyperbilirubinemia (774.6, Unspecified fetal and neonatal jaundice) and you order phototherapy.